ANAEMIA IN PREGNANCY

1. ANAEMIA IN PREGNANCY BY Dr. Shumaila Zia

2. ANAEMIA IN PREGNANCY Commonest medical disorder. High incidence in underdeveloped countries Increased Maternal morbidity & mortality Increased perinatal mortality

3. ANAEMIA IN PREGNANCY Definition: By WHO Hb. < 11 gm /dl (or haematocrit <32%). Mild anaemia -------- 9 -10.9 gm /dl Moderate anaemia--- 7-8.9 gm /dl Sever anaemia-------- < 7gm /dl Very sever anaemia-- < 4gm/dl

4. ETIOLOGY There are 3 main causes: 1- Erythrocyte production: (hypo proliferative anemia ) . Fe deficiency . Folic acid . Vitamin B12 2- RBC destruction: 3- RBC loss: 90% anemia in pregnancy is due to Fe deficiency

5. Physiological changes in pregnancy • Plasama volume 50% (by 34weeks) • But RBC mass only 25% • Results in haemodilution : • Hb Haematocrit RBC count • No change in MCV or MCH • 2-3 fold increase in Fe requierment. • 10-20 Fold increase in folate requirement

7. Common Anaemias in pregnancy Common types: Nutritional deficiency anaemias - Iron deficiency - Folate deficiency - Vit. B12 deficiency Haemoglobinopathies: - Thallassemias - SCD Rare types: - Aplastic - Autoimmune hemolytic - Leukemia - Hodgkin’s disease - Paroxysmal nocturnal haemoglobinurea

8. IRON DEFICIENCY ANAEMIA Iron required for fetus and placenta ------- 500mg. Iron required for red cell increment ------- 500mg Post partum loss --------- 180mg. Lactation for 6 months - 180mg. Total requirement -------1360mg 350mg subtracted (saved as a result of amennorrhoea) So actual extra demand ----------------------1000mg Full iron stores --------------------------------1000mg

9. ETIOLOGY OF IRON DEFICIENCY ANAEMIA Depleted iron stores – dietary lack, chronic renal failure, worm infestation, chronic menorrhagia Chronic infections: ( like malaria) Repeated pregnancies : - with interval < 1 year - blood loss at time of delivery - multiple pregnancy. CLINICAL FEATURES Symptoms usually in severe anaemia - Fatigue - Giddiness - Breathlessness

10. EFFECTS OF ANAEMA IN PREGNANCY • . Mother : • High output Cardiac failure (more likely if precelampsia present. inadequate tissue oxygenation increase requirments for excessive blood flow ) • PPH • Predisposes to infection • Risk of thrombo-embolism • Delayed general physical recovery esp after c. section • Fetus: . IUGR . Preterm birth . LBW . Depleted Fe store . Delayed Cognitive function.

11. INVESTIGATIONS Hb Haematocrit RBC Indices: - Low MCV - Low MCH - Low MCHC - Low PCV Peripheral blood picture : Microcytic Hypochromic anaemia .

12. INVESTIGATIONS Serum iron decreased (<12 micro mol / l) Total iron binding capacity :TIBC in non-pregnant state is 33% saturated with iron .when serum iron level fall ,<15% ofTIBC saturated.by fall in saturation,the TIBC INCREASED. S. ferritin :In healthy adults ferritin circulate in plasma in range of 15_300 pg/l. in iron deficiency anemia it is the first test to become abnormal.

13. Serum transferrin receptor(TfR) : present on all cells as transmembrane protien that binds transferrin iron and transfer it to cell interior. Increased in iron def. anemia. Bone marrow examination. RFTS/LFTS. Urine for haemturia. Stool examination for ova ,cyst and occult blood.

14. MANAGEMENT • Objectives: 1- To achieve a normal Hb by end of pregnancy 2- To replenish iron stores • Two ways to correct anaemia: I- Iron supplementation . Oral Fe . Parenteral Fe II- Blood transfurion • Choice of method: It depends on three main factors: • Severity of the anaemia • Gestational Age. • Presence of additional risk factor

15. MANAGEMENT Recommended supplementation for non-anaemiac 30 - 60mg /day of elemental iron Anaemic gravidas 120 –240mg / per day In tolerance to iron tablets – enteric coated tablet / liquid suspension Supplementation with folic acid + Vit C. Therapeutic results after 3 weeks – rise in Hb % level of 0.8gm/dl/ week with good compliance. Treatment continued in the postpartum period to fill the stores

16. MANAGEMENT Severe anaemia: (Hb < 8gm/dl)- preferably parenteral theraphy in the form of I/M or I/V iron - I/M : ( Iron sorbitol) with “Z” technique - I/V : (iron sucrose) Iron neede = (Normal Hb – Pt. Hb)* Wt in Kg*2.21+1000)

17. MANAGEMENT Dose given I/M or I/V by slow push 100mg / day or the entire dose given in 500 ml N/S slow I/V infusion over 1-6 hours • Marked increase in reticulocyte count expecred in 7-14 d Blood transfusion: • may be required to treat severe anaemia near term or when some other complication such as placenta praevia present. • Gross anaemia • Packed red cells transfusion (Under cover of loop diuretic) • Exchange transfusion (Under cover of loop diuretic)

18. MANAGEMENT Side effect of Fe Oral therapy: . G. I upset. . Constipation. . Diarrhoea. Parentral: - skin discolouration - local abscess - allergic reaction - Fe over load.

19. MEGALOBLASTIC ANAEMIA • Complicates upto 1% of pregnancies • Characterized by : - RBC with high MCV - White blood cells with altered morphology (hypersegmented neutrophils). • Usually caused by : - Folate deficiency may occur after exposure to sulfa drugs or hydroxyurea - Vitamin B12 deficiency

20. FOLATE DEFICIENCY ANAEMIA At cellular level Folic acid reduced to Dihydrofolicacid then Tetrahydro-folicacid . (THF) e is required for cell growth & division. So more active tissue reproduction & growth more dependant on supply of folic acid. So bone marrow and epithelial lining are therefore at particular risk.

21. FOLATE DEFICIENCY ANAEMIA Folic acid deficiency more likely if . Woman taking anticonvulsants. . Multiple pregnancy. . Hemolytic anemia; thalasemia H.spherocytosis Maternal risk: Megaloblastic anemia Fetal risk: Pre-conception deficiency cause neural tube defect and cleft palate etc.

22. FOLATE DEFICIENCY ANAEMIA - Hypersegmented neutrophils (> 5 lobes) - Neutropenia - Thrombocytopenia Low Serum folate level. Low RBC folate. Diagnosis: Increased MCV ( > 100 fl) Peripheral smear: - Macrocytosis, hypochromia

23. FOLATE DEFICIENCY ANAEMIA Daily folate requirement for : Non pregnant women -- 50 -100 microgram Pregnant woman –-------- 300-400 microgram Usually folic acid present in diets like fresh fruits and vegetables and destroyed by cooking. Folate deficiency: - 0.5-1.0mg folic acid/day If F/Hx. of neural tube defect - 4mg folic acid/day.

24. Vitamins B12Deficiency • It is rare Occurs in patients with gastrectomy , ileitis, illeal resection, pernicious anaemia, intestinal parasites. • Diagnosis: • Peripheral smear • Vitamin B12 level < 80 pico g/ml • Treatment of B12 Deficiency: • Vit B12 1mg I/M weekly for 6 weeks.

25. HAEMOGLOBINOPATHIES. Normal adult Hb. after age of 6 month, HbA---97%, HbA2---(1.5-3.5%), HbF2--<1%. 4 Globin chains associated with haem complex. Hb. A = 2 alpha +2 beta globin chains. Hb.A2= 2alpha+2 delta globin chains. Hb.F = 2 alpha+ 2 gamma globin chains. Hb. synthesis is controlled by genes. Alpha chains by 4 gene,2 from each parent. Beta chains by 2 genes ,1 from each parent.

26. HAEMOGLOBINOPATHIES DEFINITION: Inherited disorders of haemoglobin. Defect may be in: - Globin chain synthesis------thallassemia. - Structure of globin chains-sickle cell disease. Hb.abnormalities may be: - Homozygous = inherited from both parents. (Sufferer of disease) - Hetrozygous = inherited from one parent. (Carrier/trait of disease)

27. THALASSAEMIAS The synthesis of globin chain is partially or completely suppressed resulting in reduced Hb. content in red cells,which then have shortened life span. TYPES: - Alpha thalassaemia. - Beta thalassaemia: . Major . minor

28. Beta thallassemia minor Beta Thallassemia trait Heterozygous inheritance from one parent. Most frequent encountered variety. Partial suppression of the Hb. synthesis. Mild anaemia. Investigations: Hb----around 10 g/dl. Red cell indices: low MCV. low MCH. normal MCHC. Diagnostic test: Hb. Electrophoresis.

29. Beta Thallassemia Minor Management: Same as normal woman in pregnancy. Frequent Hb. Testing. Iron & folate supplements in usual dose. Parenteral iron should be avoided. because of iron overload. If not responded ---I/M folic acid. blood transfusion close to time of delivery.

30. Beta Thallassaemia Major Homozygous inheritance from both parents. Sever anaemia. Diagnosed in paediatric era. T/m: is blood transfusion. ALPHA THALASSAEMIA: Both heterozygous & homozygous forms exist. Alpha thallassaemia trait. HbH disease. Alpha thallassaemia major.

31. SICKLE CELL SYNDROME. Autosomally inherited . Structural abnormality. HbS - susceptible to hypoxia, when oxygen supply is reduced. Hb precipitates & makes the RBCs rigid & sickle shaped. Heterozygous----HbAS. Homozygous-----HbSS. Compound heterozygous---HbSC etc.

32. Sickle Cell Disease (SCD) Sickeling crises frequently occurs in pregnancy, puerperium &in state of hypoxia like G/A and Hag. Increased incidance of abortion and still birth growth restriction, premature birth and intrapartum fetal distress with increased perinatal mortality. Sickle cell trait:(carrier state) Does not pose any significance clinical problems

33. SCD Diagnosis: - Hb. Electrophoresis - Sickledext test is screening test Management: - No curative Tx. - only symptomatic - Well hydration, effective analgesia, prophylactic antibiotics, O2 inhalation, folic acid, oral iron supplement (I/V iron is C/I), blood transfusion

35. Management During labour Comfortable Position Adequate analgesia O2 inhalation Low threshold of assisted delivery Avoid ergometrine Prophylactic antibiotics Continue iron &folate therapy for 3 mo after delivery Appropriate contraceptive advice